2020 Pediatric

Dental Plans

Good oral health is good for overall health

For Washington residents under age 19 living in select counties.

Benefits

• Our dental plans include access to a broad network of dentists who work with Premera to help manage costs, quality, and services.

• Your child will get a range of covered services, including two visits and cleanings each year, plus x-rays if needed. Basic dental services—such as fillings and extractions—are covered.

• There is no waiting period for any service. Children covered under a Premera pediatric dental plan can get care as soon as coverage starts.

YOU PAYup to annual deductible

WE BOTH PAYcoinsurance for covered services

WE PAY 100% after out-of-pocket maximum is met

What are the costs?

Pediatric dental plans are charged separately from medical plans.

• �You�will�pay�a�$29.68�monthly�rate�per�child�for�the�first�3�children�covered.�If�you�have�more�than�3�children�covered�under�the�plan,�you won’t pay a monthly rate for any of the additional children.

• After the annual deductible is met, you will be responsible for paying a part of the cost of services included in the plan until you reach the out-of-pocket maximum. (This is called coinsurance.) You will have a separate deductible to meet for each child covered under the plan before coinsurance begins.

• Once you reach the out-of-pocket maximum, the plan will pay for 100 percent of covered services for the rest of the year.

Who is eligible for Premera’s pediatric dental plans?

If your medical plan covers dependents under age 19, federal law requires you to buy a pediatric dental plan from either Premera or another company.

You can get a pediatric dental plan from Premera if you live in one of the following counties:

Franklin

Grays Harbor

King

Kitsap

Pacific

Skamania

Wahkiakum

What will you pay?

You’ll pay less when you visit a provider within the Premera Dental Select network. If you receive care from an out-of-network�provider,�there�is�no�limit�to�your�out-of-pocket�costs.�To�find�an�in-network�provider,� use the Find a Doctor tool at premera.com.

The�following�costs�are�for�January�1�through�December�31,�2020.Annual deductible (the amount you pay before the plan starts to pay) $65 per calendar year, per child

Out-of-pocket maximum for in-network coverage (the most you will pay for covered services if you use a contracted provider)

$350 per calendar year, per child$700 per calendar year, per family

Diagnostic and preventive:

These include the most common services: routine exams, x-rays, cleanings,�fluoride,�and�sealants.

Basic: These�services�include�fillings,�simple�extractions,�and�periodontal�maintenance.

Major: These are usually more complex services such as crowns, dentures, bridges, and oral surgery.

PCY = per calendar year

COVERED SERVICES COINSURANCE

Diagnostic/Preventive In-network Out-of-networkRoutine oral exams limited to 2 PCY

10% 30%

Cleanings limited to 2 PCY

Fluoride treatments�limited�to�3�PCY

Oral hygiene instruction 2 appointments PCY, ages 8 and under

Complete series or panoramic x-ray�once�every�36�consecutive�months

Sealants permanent bicuspids and molars only

Fixed space maintainers designed to preserve space for permanent teeth, ages 12 and under

BasicEmergency palliative treatment

20% 40%

Limited oral evaluations—problem focused (emergency)

Fillings limited to once every 24 months

Recement or rebond permanent crowns limited to ages 12 to 19

Repair of crown limited to once per tooth per lifetime

Full-mouth debridement limited�to�once�every�3�years

Periodontal maintenance�ages�13�to�19,�limited�to�4�PCY

Simple extractions

MajorEndodontic (root canal) treatment limited to permanent teeth only

50% 50%

Periodontal scaling�limited�to�once�per�quadrant�every�24�months,�ages�13�to�19

Oral surgery including surgical extractions

General anesthesia or intravenous (conscious) sedation covered when necessary due to age, condition,�or�degree�of�difficultyIndirect crowns on permanent anterior teeth, limited to once every 5 years, for children ages 12 to 19

Resin base partial denture�limited�to�once�every�3�years

Complete dentures limited to 1 per lifetime

Occlusal guard covered for bruxism, ages 12 to 19

Orthodontics* for medically necessary conditions such as cleft lip and palate and craniofacial anomalies

*You must get approval from your health plan before your child gets orthodontic care.

This�is�only�a�summary�of�the�major�benefits�provided�by�our�plans.�This�is�not�a�contract.�Please�see�premera.com/SBC�for�the�Summary�of�Benefits�and�Coverage�and�the�glossary.�On�our�website,�you�can�also�find�a�Supplemental�Guide�with�information�about�privacy�policies,�provider�organization,�and�utilization�management�procedures.

Premera Blue Cross is an independent licensee of the Blue Cross Blue Shield Association 042326 (9-01-2019)

Definitions

Allowed amount

The amount providers contracted with Premera have agreed your health plan will pay for covered services or supplies. In-network providers cannot bill you for charges above the allowed amount. Out-of-network providers may charge more than the allowed amount and you would be responsible for paying the cost.

In-network provider

Dentists and other healthcare providers who are contracted with Premera to provide services and supplies at negotiated rates (called allowed amounts). You usually pay less when seeing in-network providers.

Out-of-pocket maximum

The maximum amount of money you will pay for health services when you visit in-network providers. Once you’ve paid this amount, your plan pays 100 percent of the allowed amount for services received from in-network providers. This maximum does not apply when you visit out-of-network providers.

Out-of-network provider

Dentists and other healthcare providers who have not contracted with Premera and have not agreed to negotiated prices. Depending on the out-of-network provider, the services could cost you more.

To find out moreVisit premera.com.

An independent licensee of the Blue Cross Blue Shield Association 037397 (11-06-2019)

Discrimination is Against the Law

Premera Blue Cross (Premera) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Premera does not exclude people or treat them differently because of race, color, national origin, age, disability, sex, gender identity, or sexual orientation. Premera provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, audio, accessible electronic formats, other formats). Premera provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact the Civil Rights Coordinator. If you believe that Premera has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator ─ Complaints and Appeals, PO Box 91102, Seattle, WA 98111, Toll free: 855-332-4535, Fax: 425-918-5592, TTY: 711, Email AppealsDepartmentInquiries@Premera.com. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Ave SW, Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Language Assistance ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 800-722-1471 (TTY: 711). 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 800-722-1471（TTY：711）。 CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 800-722-1471 (TTY: 711). 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 800-722-1471

(TTY: 711) 번으로 전화해 주십시오. ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 800-722-1471

(телетайп: 711). PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad.

Tumawag sa 800-722-1471 (TTY: 711). УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби

мовної підтримки. Телефонуйте за номером 800-722-1471 (телетайп: 711). ប្រយ័ត្ន៖ បរើសិនជាអ្នកនិយាយ ភាសាខ្មែរ, បសវាជំនួយខ្ននកភាសា បោយមិនគិត្ឈ្ន លួ

គឺអាចមានសំរារ់រំបរ ើអ្នក។ ចូរ ទូរស័ព្ទ 800-722-1471 (TTY: 711)។ 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。800-722-1471（TTY:711）まで、お電話にてご連絡ください。

ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ

800-722-1471 (መስማት ለተሳናቸው: 711). XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 800-722-1471 (TTY: 711).

.(711: والبكم الصم هاتف رقم) 800-722-1471 برقم اتصل. بالمجان لك تتوافر اللغوية المساعدة خدمات فإن اللغة، اذكر تتحدث كنت إذا: ملحوظةਧਿਆਨ ਧਿਓ: ਜੇ ਤੁਸੀਂ ਪੰਜਾਬੀ ਬੋਲਿੇ ਹੋ, ਤਾਂ ਭਾਸ਼ਾ ਧਵਿੱਚ ਸਹਾਇਤਾ ਸਵੇਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਿ ਹੈ। 800-722-1471

(TTY: 711) 'ਤੇ ਕਾਲ ਕਰੋ। ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung.

Rufnummer: 800-722-1471 (TTY: 711).

ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວົ້າພາສາ ລາວ, ການບໍລິການຊ່ວຍເຫຼືອດ້ານພາສາ, ໂດຍບໍ່ເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທຣ 800-722-1471 (TTY: 711).

ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 800-722-1471 (TTY: 711). ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 800-722-1471 (ATS : 711). UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 800-722-1471 (TTY: 711). ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 800-722-1471 (TTY: 711). ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero

800-722-1471 (TTY: 711). .ديریبگ تماس TTY: 711)-722-800) 1471 با. باشد یم فراهم شما یبرا گانيرا بصورت یزبان التیتسه د،یکن یم گفتگو فارسی زبان به اگر: توجه